REFRACTIVE ERRORS: A) HYPERMETROPIA B) MYOPIA C) ASTIGMATISM D) ANISOMETROPIA E) ANISEIKONIA

Mohd Rafiuddin Hamidon

Errors of Refraction
Emmetropia: State of refraction where the parallel rays of light coming from infinity are focused at sensitive layer of retina Ametropia: State of refraction when parallel rays of light coming from infinity are focused in front or behind the sensitive layer of retina

EMMETROPIA

NORMAL EYE

Hypermetropia

Long sightedness Posterior focal point behind the retina which therefore receives a blurred image

Etiology

Axial hypermetropia - Total refractive power of eye is normal but there is an axial shortening of eyeball Curvature hypermetropia - Curvature of cornea or lens or both is flatter than the normal resulting in a decrease in the refractive power of eye Index hypermetopia - Decrease in refractive index of lens in old age and under treatment of diabetis Positional hypermetropia - Posterior placed of crystalline lens Absence of crystalline lens congenitally or acquired leads to aphakia

Clinical types
Simple or developmental hypermetropia Developmental, axial hypermetropia Developmental curvatural hypermetropia 2. Pathological hypermetropia Index hypermetropia (cortical sclerosis) Positional hypermetropia (Posterior sublaxation of lens) Aphakia (Absence of lens) Consecutive hypermetropia (over-corrected myopia) Pathological axial hypermetropia (Forward displacement of retina) Pathological curvatural hypermetropia (Post traumatic corneal flattening) Pseudophakic hypermetropia (inplantation of underpower intraocular lens) 3. Functional hypermetropia Paralysis of accomodation as seen in third nerve paralysis
1.

Components of hypermetropia
Total hypermetropia - Total amount of refractive error which estimated after complete cycloplegia with atropine 1. Latent hypermetropia - Amount of hypermetropia which is normally corrected by inherent tone of ciliary muscle 2. Manifest hypermetropia (remaining not corrected) - Facultative hypermetropia (patient accomodative effort) - Absolute hypermetropia

Clinical features
Symptoms: Asymptomatic Asthenopic symptoms (tiredness of eyes, frontal headache, watering and mild photophobia) Defective vision with asthenopic symptoms Defective vision only Signs: Size of eyeball small Cornea small Ant. Chamber shallow Retinoscopy and autorefractometry reveal hypermetropia Fundus examination- small optic disc A-scan untrasonography- short antero-posterior length of eyeball

Complications

Recurrent styes, blepharitis of chalazia Accomodative convergent squint Amblyopia Predisposition to develop primary narrow angle glaucoma

Treatment
Optical treatment 1. Total amount of hypermetropia should always be discovered by performing refraction under complete cycloplegia 2. The spherical correction given should be comfortably acceptable to the patient 3. Gradually increase spherical correction at 6 months intervals 4. Full cyclopegic correction needed in accomodative convergent squint 5. Full correction with occlusion therapy in amblyopia 6. Spectacles 7. Contact lenses

Aphakia
Absence of crystalline lens Causes: Congenital Surgical aphakia Aphakia due to absorption of lens matter Traumatic extrusion of lens Posterior dislocation of lens

Clinical features
Symptoms: Defective vision Erythropsia and cyanopsia (seeing red and blue images) Signs: Limbal scar Anterior chamber deeper Iridodonesis-tremulousness of iris Pupil jet black Purkinje;s image test show two images Fundus examination shows hypermetropic small disc Retinoscopy and autorefractometry reeal hypermetropia

Treatment
1. Spectacles +10D with cylindrical lenses 2. Contact lenses 3. Intraocular lens implantation Primary- during cataract surgery Secondary- already aphakic patient 4. Refractive corneal surgery Keratophakia and epikeratophakia Hyperopic Lasik

MYOPIA
Short sightedness Etiology Classification: 1. Axial myopia ( anteroposterior length eyeball) 2. Curvatural myopia ( curvature of lens) 3. Positional myopia (anterior placement) 4. Index myopia ( refractory index) 5. Myopia due to excessive accomodation Grading: Low myopia: <-3D Moderate myopia: -3D to -6D High myopia: >6D

MYOPIA

Clinical varieties
1. 2. 3. 4. i)

ii)
iii) iv) v) vi) vii)

Congenital myopia Simple or developmental myopia Pathological or degenerative myopia Acquired myopia Post keratitic Post traumatic Drug induced Pseudomyopia Space myopia Night myopia Consecutive myopia

Congenital myopia

Present since birth (2-3 years) Anisometropia High degree of error (8 to 10D) Convergent squint (10-12cm) Associations (cataract, micropthalmos, aniridia, megalocornea,congenital seperation of retina) Early correction is desirable

Simple myopia
Clinical pictures: Symptoms: Poor vision for distance Asthenopic symptoms Half shutting of eye Signs: Prominent eyeball Anterior chamber deeper Pupils large Fundus is normal Magnitude of refractive error (-0.5 +/- 0.30 every year)

Pathological myopia

Rapidly progressive error which start at childhood at 5-10 years of age result in high myopia (>6D) 2% of population

Clinical features: Symptoms: Defective vision Muscle volitantes (floating black opacity in front of eye) Night blindness Signs: 1. Prominence eyeball 2. Cornea large 3. Anterior chamber deep 4. Pupil large 5. Fundus examination reveals: a) large and pale optic disc b) Degenerative changes in retina and choroid c) Posterior staphyloma (ectasiaod sclera) d) Degenerative cahnges in vitrous (liquefaction, opacities)
6.

Visual fields show contraction

Complications
1.

2.
3. 4. 5.

Retinal displacement Complicated cataract Vitreous hemorrhage Choroidal hemorrhage Strabismus fixus convergence

Treatment
1.

2. 3. 4. 5.

Optical treatment of myopia (appropriate concave lenses) by spectacle or contact lens Surgical treatment General measures (diet rich in vitamin and protein) Low vision aids (LVA) Prophylaxis (genetic counselling)

ASTIGMATISM
Refraction varies in the different meridia of eye The rays of light entering the eye cannot converge to a point focus but form focal line Types: Regular Irregular

Regular astigmatism
Types: 1. With-the-rule astigmatism (WTR) Two principal meridia are placed at right angle to one another but the vertical meridian is more curve than horizontal 2. Against-the-rule astigmatism (ATR) - Horizontal meridian is more curved than vertical meridian 3. Oblique astigmatism - Two princpal meridia are not the horizontal and vertical though these are at right angle to one another 4. Bioblique astigmatism - Two principal meridia are not at right angle to each othe

Refractive types of regular astigmatism

1.

2.

3.

Simple astigmatism Rays focused on retina in one meridian and either in front or behind retina Compound astigmatism Rays both meridian are focused either in front or behind the retina Mixed astigmatism Light rays in one meridian are focused in front and in other meridian behind the retina

Symptoms: 1. Asthenopia (tiredness of eyes relieved by closing the eyes) 2. Blurred vision and defective vision 3. Elongation of object vision 4. Keeping the reading materials close to the eye Signs: 1. Half closure of the lid 2. Head tilt 3. Oval or tilted optic disc 4. Different power in two meridia

Investigations: 1. Retinoscopy reveals different power in two different axis 2. keratometry: reveals different corneal curvature in two different meridia 3. Astigmatic fan test (Jacksons cross cylinder) To confirm the power and axis of cylindrical lenses

Treatment
Optical treatment - Spectacles Contact lenses 2. Surgical correction is quite effective
1.

NORMAL EYE

SYMMETRICAL LIGHT REFLEXION

ASTIGMATISM

UNEQUAL CRESCENT FORMATION

Irregular astigmatism
Irregular change of refractive power in different meridia Clinical features: Symptoms: 1. Defective vision 2. Distortion of object 3. Polypia (multiple images) Signs: 1. Retinoscopy reveals irregular pupillary reflex 2. Slitlamp examination reveals keratoconus 3. Placidosdisc test reveals distorted circles 4. Photokeratoscopy and computerised corneal topography reveal irregular corneal curvature

Treatment
1.

2.

3.

Optical treatment- contact lenses Phototherapeutic keratectomy (PTK)excimer laser Surgical treatment indicated in extensive corneal scarring

ANISOMETROPIA
Total refraction of the two eyes is unequal Clinical types: 1. Simple anisometropia One eye normal, other myopic or hypermetropic 2. Compound anisometropia Both eye hypermetropic of mycopic but one eye have more refractive error 3. Mixed anisometropia One eye mycopic other hypermetropic 4. Simple astigmatic anisometropia One eye normal, other simple myopic of hypermetropic astigmatism 5. Compound astigmatism anisometropia Both eye astigmatism but unequal degree

Treatment
1.

2.
3. 4. a) b) c)

Spectacles max. 4D Contact lenses in higher degree Aniseikonic glasses Others: Intraocular lens implantation Refractive corneal surgery Phakic refractive lenses (PRL) and refractive lens exchanges (RLE)

ANISEIKONIA

The images projected to visual cortex from the two retinae are abnormally unequal in size and shape

Clinical types: 1. Symmetrical aniseikonia i) spherical, ii) cylindrical 2. Asymetrical anisekonia i) Prismatic ii) Pincushion iii) Barrel distortion iv) Oblique distortion

Symptoms: 1. Asthenopia- eyeache,browache, tiredness of eye 2. Diplopia 3. Difficulty in depth perception Treatments: 1. Optical aniseikonia- glasses, contact lenses 2. Retinal anisekonia 3. Cortical aniseikonia